2016_0814 CITY OF COPPELL WATER UTILITIES
��:- - �. -:,�; ,� CUSTOMER SERVI`�E INSPECTION
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Residential [� Commercial ❑ TNRCC ID#0570040
I��O t�i �.,% (� ��Q � / � ,upon inspection of the private water distribution facilities located at
7 3� ��'�,�2-,��,t,,,r� , which is connected to the Ciry of Coppcll Water System, do hereby certify
that,to the best of my knowledge:
"' In Non- N/A
Compli Compliance
(1) No d'uect connection between the public dr�nking water supply and a potenrial � � ❑
source of contaminarion exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water � ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
prevenrion assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing � p p
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water I�" ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or tlux which contains more than 0.2% lead exists in private water f,�` ❑ ❑
distribution facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution faciliries until the above condirions are determined ta be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion faciliries located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper O� / PVC O Other F�l/
o er Lead ❑ Lead Free L� Solvent Weld ❑ Other C�' •
I�recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the v lidity of the information I have provided.
�^ �� � �� 7 �
ature of Licensed Plumber Registration Number
1� ��1 F �����1�r
Type of Regis�ation Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
//J^ -�J 2 � � J�,/S / S
S' ture of Inspector Registration N ber
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Type of Registration Date
White-Customers Copy Yellow-Ciry's Copy Pinlc-Inspeaors Copy